Health Humanities Undergraduate Research

Abstract:

This paper focuses on analyzing the historical information on the “father of gynecology” Dr. Marion J. Sims, and how his unethical and nonconsensual procedures on enslaved black women contributed to the modern healthcare disparities, specifically black women, seen in healthcare today. Dr. Marion J. Sims was an American physician in the mid-1800s who focused on treating women’s disease. He became considered the “father of gynecology” after he discovered the technique for repairing vesicovaginal fistulas, which is a childbirth complication in which an opening occurs between the vaginal walls and the bladder. While Sims had made great strides to fix this childbirth complication for women, the ways he went about it were unethical as he performed experimental surgeries on enslaved women without their consent. This research paper questions the ramifications of Dr. Sims' experiments and treatment of enslaved black women on the modern healthcare disparities in women’s healthcare today and was performed by analyzing and reading through a variety of sources that described both the historical aspect of women’s healthcare and the modern-day issues present. The findings display that there is a direct connection between the mistreatment of enslaved black women and the disparities seen in the healthcare of black women today, based on the historical analysis performed and the modern-day statistics and patient testimonies examined. The implications of this demonstrate that the United States' deeply racist history has a significant impact on the healthcare minorities receive today. This work is significant as it works to spread awareness of the effects of racism on the United States healthcare industry and to work to reduce racial disparities seen in black women’s gynecological care and ensure they receive the proper healthcare they need and medical professionals are trained effectively to do so.

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Historical Analysis:

The 1840s was a time period when major scientific and medical developments were developed, primarily in the gynecological field. One doctor, in particular, is credited with significant findings in modern gynecology, Dr. James Marion Sims, who in the mid-eighteen hundreds infamously coined his “groundbreaking” surgical technique for vesicovaginal fistula repair that was thought to be the beginning of what we know today as modern gynecology. Sims’s story is known worldwide, and he is renowned as the “Father of Modern Gynecology”. While his discoveries credited him with this title the ethics surrounding his discoveries make him a controversial figure. A lesser-known story is that of the true mothers of gynecology, the enslaved black women whom Sim’s discoveries based through his experiments performed both without anesthesia and consent. Over the span of four years, “Sims performed experimental surgeries, without their consent and without the benefit of anesthesia, on at least 14 enslaved black women” (Khabele et al. sec. 1). To explore a new surgical technique, Sims sought out enslaved women who had been plagued with fistulas and made deals with their owners promising to find a cure.

While many of the women’s names were not mentioned within historical texts, three were repeatedly brought up in Sims’ work. Their names are Anarcha, Betsey, and Lucy. The three women were acquired by Sims’ based on an arrangement he made with the slave owner who considered these women their property. Sim’s proposition: “If you will give me Anarcha and Betsey, I agree to perform no experiment or operation on either of them to endanger their lives, and will not charge a cent for keeping them, but you must pay their taxes and clothe them” (Wailoo, par. 4). The owners were willing to participate in this exchange due to the conditions that several enslaved black women developed after childbirth: vesicovaginal fistulas. This post-partum complication, an opening that forms between the bladder and the vaginal walls, results in severe abdominal pain and the leakage of urine and other fluids. Enslaved black women were vulnerable and were likely to develop the condition as a result of “poor nutrition, lack of prenatal care, and births at an early age” (Ojanuga 1993). The condition is not able to heal on its own and requires medical intervention. Dr. Sims worked to perfect a restorative operation on vesicovaginal fistulas, repeatedly operating on the enslaved black women he had acquired. 

Under Sims, each woman underwent up to thirty operations over four years, allowing him to refine his technique, with each procedure, they were provided no anesthetics (Wailoo par.5). His previous promises to cause the women “no harm” held little weight at this time as the prevalent notion in the medical community was that black individuals did “not feel pain”. His contemporary, Dr. Cartwright, claimed that the black body was “insensible to pain” and “more tolerant to hard labor” (Wailoo par. 8). To this day, defenders of Sim’s excuse his cruelty as being a product of the underdeveloped scientific knowledge about the human body during this time. Despite these false claims, there is significant evidence that demonstrates the pain and endangerment that these women faced.  In one instance, Lucy’s surgery “lasted for an hour and Lucy endured excruciating pain while positioned on her hands and knees” (Ojanuga 1993). Ojanuga described how degrading the process was and detailed how “she must have felt extreme humiliation as twelve doctors observed the operation” (Ojanuga 1993). Anarcha’s story mirrors Lucy, highlighting the excruciating pain, humiliation, and lack of consent throughout the procedures. A particularly disturbing poem written by Anarcha Wescott, one of Sim’s other victims, detailed the horrors she endured in order to further Dr. Sim’s discoveries. She wrote of how Sims forced “four strong field hands to hold me down, kneeling, he doesn't say nothing to me” (Armstrong lines 33-35) and how he would say “shut up gal and a hand over the mouth”(Armstrong line 38). She wrote, “Doctor cut us so many times, sew us this way, sew us that way. But the stitches still take” explaining that she had “no say” and describing fields hands holding her down as she screamed and bled time she fainted, saying “he cuts me inside–I feel the blood runnin’ down my legs to the floor–then he picks up the curved needles–and it goes on and on till I pass out” (Armstrong lines 42-45). This is especially disturbing considering the claims that Sim’s had made regarding consent, writing:

I was fortunate in having three young healthy colored girls given to me by their owners in Alabama, I agreeing to perform no operation without the full consent of the patients, and never to perform any that would, in my judgment, jeopard life, or produce greater mischief on the injured organs—the owners agreeing to let me keep them (at my own expense) till I was thoroughly convinced whether the affection could be cured or not (Wall, 1302).

The accounts of his victims, described above, invalidate these claims, and show that the ideas of informed consent and bodily autonomy were completely ignored for him to climb the ranks to being highly regarded in the medical community. While he may have achieved his goal and been named the so-called “father of gynecology”, it was only possible through the emotional trauma and non-consensual exploitation of the black women who fell victim to his experiments. He used these women as disposable “Guinea pigs” for perfecting these dangerous procedures before he brought them worldwide, to rich white women, whom he never operated on without anesthesia (Khabele et al. sec. 1). After Sims had perfected his technique of repairing vesicovaginal fistulas and had spread awareness of his discovery, he began performing the surgery on white women as well, however, it was noted that while many white women came to Sims for treatment, “none of them were able to endure a single operation” (Ojanuga 1993). This blatantly displays how painful the procedures truly were, however, due to Sims' implicit racial bias and disregard for the women he was experimenting on, he failed to regard their pain and would continue to operate on them despite their screams. This occurred even after he had defended his un-anaesthetized treatments and claimed that he would “never resort to them [anesthetics] in these operations, because they are not painful enough to justify the trouble, and risk attending their administration” (Wall). However, another physician during Sims’ time, named Dr. Crawford W. Long, removed a tumor from his patient James Vernable in 1842 “using sulfuric ether as an anesthesia” (Ojanuga 1993). He was regarded as the “first doctor to perform a surgical operation in which a patient suffered no pain” (Ojanuga 1993). This revelation occurred prior to Sims’ experimentation, displaying how methods of anesthesia had been established, but Sims intentionally chose the absence of anesthesia because he disregarded black women’s pain, and the disregarding of black women’s pain is still a prevalent situation today.  Additionally, the idea that anesthetics and consent were not the “order of the day”, due to the time period being that of slave-holding society, is not entirely true. There are multiple medical discoveries that were made during this time that did not include the use of slaves and included the idea of consent. In fact, it was rare to use enslaved individuals in the experimental medical context as they most often “worked as field-hands and household servants, but they were seldom used as experimental subjects” (Ojanuga 1993). What Sims had done was not only abusive towards the enslaved women, but was also unusual and not commonly performed. He chose this option because he had little to no respect for the enslaved black women, which is also seen in the lack of consent within his experimentation. Consent was also an established idea during that time, that Sims’ blatantly ignored. For example, a physician named Ephraim McDowell, who was alive during Sims’ time, was the first successful individual to perform a successful abdominal operation. In his experiment, McDowell “removed a 22-pound ovarian tumor from Jane Todd Crawford” (Ojanuga 1993). Mrs. Crawford was a white woman who had “given her informed consent for the experiment”. According to Agatha Young, “he had called the operation an experiment, nothing more…and that she was more than likely to die while the experiment was in progress, but Jane was brave; she accepted” (Ojanuga 1993). Jane was clearly told what to expect and consensually agreed to participate in the operation. There was no evidence of Sims asking for the consent of the women to participate in the operations, he did so without informing them of what would occur and with complete and total disregard for their pain as not only would Sims make his patients suffer through his invasive procedures, but he would then tell “his enslaved patients they must now work as his assistants”, with essentially no credit given to them in his publications  (Bock par.11). When Sims did acknowledge his team of enslaved women, they were described as both smart and dignified, however, Sims staff and patients were depicted as white. This is as Cooper Owens described, an erasure of the black experience that occurred “visually and historically” (Bock par. 12 and 13). Unfortunately, the erasure of such experiences allows racism to prevail in medicine to this day. This racial prejudice is what the modern obstetrics and gynecology field was founded upon, and the effects of misinformation and implicit bias are still prevalent in the experiences of black women in modern society. Although there is a prevalent amount of information and evidence detailing how Sims severely mistreated enslaved black women, there are still texts and people who hold Sims in high regard because of his discoveries, despite the unethical ways he went about obtaining his results.

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Modern Statistics:

Today we see the “legacy” of Dr. Marion Sims in the mistreatment and silencing of black women in regard to their healthcare in terms of quality and representation. As recently as 2016, there have been reports of medical students and residents holding “unfounded and deeply mistaken beliefs about blood of black and white patients coagulating at different rates, skin of black patients being thicker than skin of white patients, and African Americans having lower sensitivity to pain” (Wailoo, par. 15). The learned implicit bias of future healthcare workers can have profound impacts on the way that they practice medicine in the future, further inducing a healthcare environment that is anything but inclusive. Many healthcare education systems do not have the educators, courses, or materials needed to properly inform them on the racial disparities within healthcare today, and how to work to lessen the divide. An example of this within the gynecological practice is the disregard of consent when completing medical training. Medical students participating in obstetrics-gynecology clerkships are not taught the moral lesson of informed consent, and it is not required as they perform “nonconsensual pelvic examinations at the start of their training” (Friesen). It has been stated that “students who have completed obstetrics-gynecology clerkships place significantly less importance on seeking permission from women who are to be anesthetized before performing pelvic examinations” (Friesen). Students are taught to disregard consent for pelvic examinations, and as a result, are more likely to implement a lack of consent within their own practices as physicians. This parallels Sims and his experimentation on enslaved black women. Sims too felt as though he did not need the informed consent of the women because he believed he had performed the surgeries on them for the advancement of medicine and educational purposes, similar to what the medical students today do. Informed consent is vital and should be taught to all healthcare professionals. Women’s bodies are not test subjects to be used, and this fact needs to be made clear to prevent nonconsensual examinations from continuing to be done on women and improve the healthcare women, especially African-Americans, receive. Again, studies have shown repeatedly proven time and time again that the quality of healthcare that black women receive is substandard at best. This is particularly present in the maternal mortality rates of black women in comparison to any other race. In 2005, a shocking study showed that out of 100,000 live births, 39.2 non-Hispanic black women died in childbirth, this compared to the 11.7 white women, is outrageously high (Bryant et al. Table 1). When trying to find a medical reason for this unfathomable gap in mortality rates, studies then “found that black women in the national sample did not have higher prevalence of preeclampsia/eclampsia, postpartum hemorrhage, placenta previa, or placental abruption, but for all 5 conditions, black women had case-fatality rate 2.4-3.3 times higher than that of white women” (Bryant et al. 338). This shows that the root of the issue is in the quality of care that black women are receiving, rather than a predisposition to common lethal conditions. A response to this issue by Dr. Camille Clare explains this phenomenon is “not because of biological differences but because of structural racism” (Clare par 1).

Outside of just mortality rates, black women are less likely to be taken seriously in any context of medicine and their requests for treatment are often brushed aside by medical professionals. Studies on frequency of pain management through the distribution of both inpatient and discharge Opioid prescriptions clearly highlight this lack of consideration for black women’s pain. It was found that “non-Hispanic white women were significantly less likely to report a pain score at discharge of 5 or higher than both Hispanic and non-Hispanic black women. Yet non-Hispanic white women received significantly greater MMEs/d [oral morphine milligram equivalents] as inpatients than Hispanic and non-Hispanic black women (par. 11). The study’s conclusion: “Hispanic and non-Hispanic black women experience disparities in pain management in the postpartum setting that cannot be explained by less perceived pain” (Badreldin et al., abstract).This clear racial bias in the validation of pain complaints only adds to the mistrust that black women have in the medical industry. Statistics have shown that the distrust in healthcare often leads to delayed entry into prenatal care, as late as after the completion of the first trimester (Bryant et al., Table 1). Not only does this put both the mother and baby more at risk for danger during delivery, but it leads to further underdiagnosed conditions and less effective treatment for many women.

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Perceived Racism and Testimonies:

There are significant racial and ethnic disparities within the United States’ health care system, specifically against African Americans. Racial and ethnic disparities in healthcare are often described as differences in the quality of care received by particular groups who have similar health insurance and the same access to a doctor when there are no differences between these groups in their preferences and needs for treatment.  This is present within every healthcare field, especially in the gynecological practice. This is an unfortunate result due to the racist history of the United States and the racial bias against black women, originating from physicians such as Marion Sims. As a result, black women have had to suffer with inadequate healthcare, their pain being ignored and their fears going unacknowledged. This idea was displayed articulately in a quote by Vanessa Cristina dos Santos Saraiva, who stated that “when addressing the situation of Black women, one cannot disregard the historical violence and sexual abuse, work exploitation and denial of the right of life, evidenced in the denied or non-assistance is accessing public services, especially health services, in primary, secondary, or tertiary care” (Saraiva). The continued implicit racism held by medical professionals and the systematic racism that is deeply integrated within the United States leads to decreased health equity and equality of black women, and this is seen through their stories. An example of this is a study that was conducted asking various American black women, between the ages of 18 to 45, in surrounding metropolitan areas, Boston, Atlanta, and Chicago, about their experiences with the reproductive healthcare system. The results display how the reproductive healthcare system has failed a vast amount of black women in getting the care they both need and deserve and how many medical professionals are not able to provide the care they vitally need. As seen in the jarring statistics and disparities, black women are at a disadvantage in terms of reproductive outcomes and risks. This is widely recognized, and one woman, regarded as participant 20, within the study discussed this saying “It just frightens me a little bit to one, think about actually going through labor, but then, also, do I have to write my will within that timeframe of being nine months pregnant, or within that year postpartum?” (Trader). She is right, labor is already an extremely nerve-wracking occurrence, and women deserve to know that their health is regarded and protected and should have trust in their medical providers. Knowing that one is at higher risk of mortality and complications just because of the color of their skin can cause a large amount of stress and anxiety, which is noted when that same participant continues to say “I don’t think people understand the type of stress that comes with knowing so much about what’s going on in the Black community” (Trader). Another participant displayed similar anxious thoughts saying “We saw the news that black women are more likely to die, and now I’m scared to get pregnant” (Trader). The mortality and morbidity rates surrounding childbirth for black women cause such anxiety that it prevents some women, as seen, from wanting to get pregnant. Every woman deserves to have the choice of if they want to bring new life into the world, and the reproductive healthcare system is failing black women daily, by allowing these justified thoughts to run through their heads. Black women are also more susceptible to not having their news acknowledged or heard when speaking with a healthcare professional. Again, medical professionals in the past repeatedly disregarded black women’s pain, creating fallacies that they are not susceptible to pain or imagining false biological bases for pain differences between races and ethnicities. This is still a prevalent idea today and is seen in the testimonies of black women’s voices being silenced. An example of this is seen in the testimonial of Dineo Khabele, an obstetrician-gynecologist herself, who had a jarring delivery experience. When going to the hospital to give birth to her child she regarded the feeling she and her husband felt entering the hospital, saying “My husband and I, a black couple with a Harlem address, were admitted to the hospital with indifference” (Khabele et al., sec. 1). She later goes on to describe her labor process saying “I tried to ask for an epidural, but my labor pains were openly mocked. It is hard to describe how humiliating it is to be dismissed when vulnerable…all I remember is wanting to be heard” (Khabele et al., sec. 1). This horrific experience Khabele underwent aligns very similarly to the experiences of the enslaved black women Marion Sims experimented on. Almost 200 years later, black women’s voices are still being ignored, having to endure feelings of humiliation and vulnerability, and their pain is still not being taken seriously. This is seen again in the testimony of Linda D. Bradley, a black physician, who came to the hospital as a victim of sexual assault, a time of such vulnerability and pain, and treated horrendously by medical professionals. She described how the chief resident of the hospital was impatient with her asking her to “open her legs now” and proceeded to try and open them himself. “Her tears meant nothing to him. He did not acknowledge her pain and fear, he did not say that he felt sorry for what had happened to her” (Khabele et al. sec. 1). Once again, a repetition of history is occurring, the same cycle. Black women’s fears and pains go unacknowledged just as the enslaved women’s feelings had, there has been little to no change in how black women are seen in the healthcare industry. As the gynecological statistics continue to rise and more and more black women continue to tell their tragic stories, mistrust within the healthcare industry continues to fester in the black community. With black women, referring back to the study, stating that they “felt like the approach of the healthcare professionals was dismissive or passive…they wondered whether racism was at play and it contributed to their mistrust in reproductive healthcare” (Trader). Black women in America have every right to be guarded and hold mistrust in the reproductive health care field, as history has shown and simply turning on the news channel today as well, that their needs will continue to go unrecognized and untreated until a significant difference is made.

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Future Avenues of Research:

The health humanities aspect of medicine, particularly the connection between the racist history of the practice of gynecology and the impacts it has on modern healthcare, is extremely under-researched and deserves more recognition. In order to work towards building a better healthcare system that serves all communities within the United States equally and respectfully, awareness of the issues needs to be brought to attention and actions need to be taken. An excellent example of this is the Baldreldin study, which found that while Hispanic women, non-Hispanic white women, and black women do not differ in perceived pain, black women experience disparities by being underdiagnosed and receiving fewer pain management medications when postpartum. This study worked to reduce racial disparities black women receive in the postpartum setting by uncovering how implicit racial bias contributed to reduced pain management medications and bringing awareness to it. Additionally, another study that is working to reduce healthcare disparities experienced by black women was the Trader study, which interviewed multiple black women in metropolitan areas on their reproductive healthcare experiences. Their study displayed the deep mistrust and reluctance many black women hold against the medical community due to the lack of listening and undermining done by medical professionals and bringing awareness to how black women today feel regarding their gynecological health. For future research, we hope to advance theirs and our own research by looking into multiple aspects of women’s healthcare, such as pain management and IUD insertions, to continue this conversation and bring awareness to the growing disparities that occur within women’s healthcare, and discover new ways to make sure women in the United States needs are met and heard.